ART Treatment Failure Screening Sheet A. Identification: UAN/HMIS No: ____________ Address: ______________ Facility_____________ B.

Socio demographic data: Age (years): ________ Sex: M F

C. Clinical information to be filled by nurse/health officer 1. Previous ART experience 2. Duration on ART (months) PMTCT (sd-NVP or combined) 6-12 12-24 24-36 None above 36 Other_______ Other_______

3. CD4 profile (start from the base line) _____________________________________________ 4. Current CD4 count to pre- treatment baseline or below Persistently below 100 for >12 months By >50% from peak value on ART Discordant response with VL Severe bacterial Crypto. meningitis CNS toxo

Other_________________________ Extra pulmo. TB Kaposi Sa Wasting syndrome PCP Lymphoma

5. Recent/current clinical WHO stage (stage 3 and/or 4 conditions or T3 and/or T4)

Other (specify)__________________________________________________________ 6. Change in functional Status in the last six months 7. Adherence in the last six months 8. Weight profile Gaining weight Good by 0-5% Working Poor by 5-10% Yes No Yes No by > 10 % Ambulatory Bedridden

Fair

9. Does the patient have potential treatment failure?

10. If suspected TF, pertinent investigations completed and referred to a physician? D. Clinical information to be filled by ART physician 11. T-stage 12. Viral load T1 T2 T3 T4 400-10000c/ml >10,000c/ml

Undetectable or <400c/ml linked to CM service

Not done Other

13. If VL <400 c/ml,

standard ART monitoring Other

14. If viral load is > 400 c/ml,

linked to second line switch team

15. Comments___________________________________________________________________ ___________________________________________________________________ E. Recommendations of the switch team (to be filled by the ART physician) 16. Switch team decided to:
Conduct additional investigation appoint for re-evaluation Switch to second line

Intensify adherence support

No TF, hence continue FLA

Other______________________________________________________________________ 17. Recommended SLA and reason why? ___________________________________________________________________________ ___________________________________________________________________________

A. Identification: It is good to have a documentation of this on each sheet as it may slip from the chart B. Socio demographic data: Please document age in years and the sex of the patient as these variables Are strongly correlated with the treatment conditions of the patient C. Clinical information to be filled by nurse/health officer: As the nurses/HOs are the forefront and the primary responsible clinician contacts for the patient, the basic screening and assessment is conducted through them. 1. Previous ART experience: This information may give a clue to differentiate between primary and secondary resistances. 2. Duration on ART (months): Screening for treatment failure starts six months after the commencement of ART. The longer the duration the higher the index of suspicion for TF 3. CD4 profile (start from the base line): Outlines the patients CD4 increment or decrement over the course of time and the corresponding Immunological response 4. Current CD4 count: The calculated current CD4 count determines whether the patient has Immunological treatment failure or good immunologic response 5. Recent/current clinical WHO stage (stage 3 and/or 4 conditions or T3 and/or T4 conditions): Emergence of stage 4/T4 defining clinical conditions are markers of clinical treatment failure 6. Change in functional Status in the last six months: Deterioration of functional status in the past Six months in conjunction with other evidences favors the diagnosis of treatment failure 7. Adherence in the last six months: Studies suggest that the most important cause of ART treatment failure is sub optimal adherence to ART. Problems in adherence lead to decrement of CD4 count and ultimately predispose the patient to resistance and treatment failure. Operationally we evaluate adherence practice in the past six months 8. Weight profile: Declining weight profile (> 5%) should alarm treatment failure 9. Does the patient have potential treatment failure? Referring to the aforementioned clinical and immunological conditions. 10. If suspected TF, pertinent investigations completed and referred to a physician: (OFT, Lipid profile, CBC.) F. Clinical information to be filled by ART physician 11. T-stage: The physician undergoes thorough and meticulous evaluation of the treatment outcome 12. Viral load: VL is requested and interpreted by the physician. VL count 0f 400 is taken as the lowest range to exclude virologic blip and any count above that marks either problem in adherence or resistance and treatment failure. G. Recommendations of the switch team (to be filled by the ART physician): The out puts of the second line switch team will be properly tracked and documented.